DC Medicaid Long-Term Care Application Packet

DC MEDICAID LONG-TERM CARE APPLICATION PACKET — DISTRICT OF COLUMBIA

TABLE OF CONTENTS

1. Cover Letter to DHCF / DHS-ESA
2. Applicant Identification and Household
3. Program Selected and Level-of-Care Basis
4. Income Disclosure
5. Resource (Asset) Disclosure
6. Primary Residence and Home-Equity Treatment
7. 60-Month Look-Back and Transfer Disclosure
8. Spousal Impoverishment / CSRA / MMMNA
9. Spend-Down / Medically Needy Pathway
10. Authorized Representative Designation
11. Document Index and Verification Checklist
12. Applicant / Representative Certification
13. DC Practice Notes
14. Sources and References

1. COVER LETTER TO DHCF / DHS-ESA

Date: [__/__/____]

To:
Department of Human Services — Economic Security Administration
Case Record Management Unit
P.O. Box 91560
Washington, DC 20090

Copy to:
Department of Health Care Finance (DHCF)
441 4th Street NW, Suite 900S
Washington, DC 20001

Re: Application for Medicaid Long-Term Care Benefits — [APPLICANT FULL LEGAL NAME], DOB [__/__/____], SSN [XXX-XX-____]

Dear Eligibility Worker:

Enclosed please find the Combined Application Form (Form 105) and supporting documentation for the above-named applicant, who is applying for ☐ Long-Term Care (Institutional) Medicaid ☐ EPD Waiver Home- and Community-Based Services. The applicant requests retroactive coverage for the three (3) months preceding the date of this application pursuant to 42 U.S.C. § 1396a(a)(34).

This packet contains the items listed in Section 11 (Document Index). Please direct any requests for additional information to the Authorized Representative identified in Section 10.

Respectfully submitted,

[________________________________]

[REPRESENTATIVE / APPLICANT NAME]

2. APPLICANT IDENTIFICATION AND HOUSEHOLD

3. PROGRAM SELECTED AND LEVEL-OF-CARE BASIS

3.1. Program elected (check one):

• ☐ Long-Term Care (Institutional) Medicaid — applicant is admitted or seeking admission to a nursing facility, ICF/IID, or similar institution
• ☐ EPD Waiver (Elderly and Persons with Physical Disabilities) — applicant requires nursing-facility level of care but elects to receive services at home or in an assisted-living / community-residence setting
• ☐ QMB / SLMB / QI Medicare Savings Program (concurrent application)

3.2. Level-of-care determination. Applicant's nursing-facility level-of-care need is documented by:

• DACL Aging and Disability Resource Center assessment dated [__/__/____]
• DHCF-approved Medical Necessity Form (LTCA-MNF) signed by [PHYSICIAN NAME, NPI] on [__/__/____]
• Diagnosis: [ICD-10 CODES + NARRATIVE]

3.3. EPD Waiver only. Applicant elects services that may include personal-care aide, homemaker, chore, respite, assisted-living facility services, environmental modifications, personal emergency response system, and case management as set forth in the approved 1915(c) waiver. Applicant has reviewed and understands the right to choose between institutional placement and home- and community-based services.

4. INCOME DISCLOSURE

4.1. Applicant monthly gross income (current month):

4.2. Institutional income cap (2026). Single applicants for institutional / waiver Medicaid must have gross monthly income under approximately $2,982 (300% of the SSI Federal Benefit Rate). Verify the current cap with DHCF before filing. Applicants over the cap must execute a Qualified Income Trust (Miller Trust) or pursue the Medically Needy spend-down pathway (Section 9).

4.3. Income deposit account (where post-eligibility income is paid): [INSTITUTION / ACCOUNT NUMBER].

5. RESOURCE (ASSET) DISCLOSURE

5.1. Asset limit (2026). Countable resources may not exceed $4,000 for a single applicant or $6,000 for a couple where both spouses apply. Confirm current limits with DHCF before filing.

5.2. Itemized resources (applicant + community spouse):

5.3. Statutorily exempt resources. Applicant claims the following exemptions:

• Primary residence (subject to home-equity cap — see Section 6)
• One automobile (regardless of value if used by applicant or community spouse)
• Household goods and personal effects
• Term life insurance and whole-life policies with face value at or under $1,500
• Up to $1,500 designated burial funds plus irrevocable pre-need burial contracts
• Real or personal property essential to self-support (subject to limits)

6. PRIMARY RESIDENCE AND HOME-EQUITY TREATMENT

6.1. Primary residence (homestead): [STREET / UNIT, WASHINGTON, DC ZIP].

6.2. Equity computation:

• Current fair-market value: $[________]
• Outstanding mortgage / liens: $[________]
• Net equity: $[________]

6.3. Home-equity cap. Federal law (42 U.S.C. § 1396p(f)) bars Medicaid long-term-care eligibility for an unmarried applicant whose home equity exceeds the federal cap (the 2026 cap is approximately $1,097,000, indexed annually). The cap does not apply if a community spouse, a child under 21, or a blind or disabled child resides in the home.

6.4. Intent to return. Applicant ☐ does ☐ does not intend to return to the primary residence. Where intent to return is asserted, the home is excluded as a resource for institutional Medicaid eligibility, although it remains subject to estate recovery (D.C. Code § 4-205.79; 42 U.S.C. § 1396p(b)).

6.5. Estate-recovery acknowledgment. Applicant acknowledges that DHCF may recover correctly paid medical assistance from the estate after the death of an applicant aged 55 or older, subject to hardship waivers.

7. 60-MONTH LOOK-BACK AND TRANSFER DISCLOSURE

7.1. Look-back period. Pursuant to 42 U.S.C. § 1396p(c) and DC eligibility rules, DHCF will review every transfer of assets by the applicant or applicant's spouse during the 60 months immediately preceding the application date. The look-back start date is [__/__/____].

7.2. Transfers during look-back. Applicant discloses the following non-exempt transfers (attach copies of deeds, account statements, gift letters, and tax returns):

7.3. Penalty divisor. DC's transfer-penalty divisor is the average monthly private-pay nursing-facility rate published by DHCF (currently approximately $12,000 / month for 2026 — confirm with the most recent DHCF Eligibility Bulletin). Applicant calculates any penalty period as: (uncompensated transfer total) ÷ (current divisor) = months of ineligibility.

7.4. Statutory exemptions claimed. Applicant claims one or more of the following safe-harbor exemptions under 42 U.S.C. § 1396p(c)(2):

• ☐ Transfer to spouse
• ☐ Transfer to a blind or disabled child of any age
• ☐ Transfer of home to a sibling with equity interest who resided in the home for at least one year
• ☐ Transfer of home to a "caregiver child" who resided in the home for at least two years and provided care that delayed institutionalization
• ☐ Transfer to a special-needs trust or pooled trust under 42 U.S.C. § 1396p(d)(4)
• ☐ Transfer for fair market value
• ☐ Hardship waiver requested

7.5. No undisclosed transfers. Applicant affirms under penalty of perjury that no transfer required to be disclosed has been omitted.

8. SPOUSAL IMPOVERISHMENT / CSRA / MMMNA

8.1. Snapshot date (date of first continuous 30 days of institutionalization or first waiver application): [__/__/____].

8.2. Community-Spouse Resource Allowance (CSRA, 2026). Maximum CSRA is approximately $162,660, with a minimum of approximately $32,532 (federally adjusted annually). Half of the couple's total countable resources at snapshot, capped at the maximum, is protected for the community spouse.

8.3. Minimum Monthly Maintenance Needs Allowance (MMMNA, 2026). Minimum MMMNA is approximately $2,555 / month through 6/30/2026; maximum is approximately $3,948 / month. The community spouse may divert the institutionalized spouse's income up to the MMMNA cap.

9. SPEND-DOWN / MEDICALLY NEEDY PATHWAY

9.1. Eligibility. Applicants whose income exceeds the categorical limit but who incur substantial medical expenses may qualify under the DC Medically Needy program, with a six-month budget period. The Medically Needy Income Level (MNIL, 2026) is approximately $809.08 / month for a household of one — confirm with DHCF.

9.2. Spend-down computation:

• Six-month gross income: $[________]
• Six-month MNIL allowance: $[________]
• Spend-down obligation: $[________]
• Allowable medical expenses incurred: $[________]
• Net spend-down balance: $[________]

9.3. Documentation submitted. Bills, receipts, EOBs, and proof of payment for all medical expenses claimed toward the spend-down obligation are filed at Tab [____].

10. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate the following individual as my Authorized Representative for purposes of this Medicaid application, including the right to receive notices, submit documents, and appear at fair-hearings on my behalf, pursuant to 42 C.F.R. § 435.923:

[________________________________] Date: [__/__/____]
[APPLICANT SIGNATURE]

11. DOCUMENT INDEX AND VERIFICATION CHECKLIST

12. APPLICANT / REPRESENTATIVE CERTIFICATION

I certify under penalty of perjury under the laws of the District of Columbia that the information provided in this application packet, including all attached schedules and documents, is true, correct, and complete to the best of my knowledge. I understand that material misstatements or omissions may result in denial of benefits, recoupment of paid benefits, civil penalties, and criminal prosecution under D.C. Code § 4-218.01 and 42 U.S.C. § 1320a-7b.

I authorize DHCF, DHS-ESA, the Social Security Administration, the Internal Revenue Service, financial institutions, and health-care providers to release records necessary to verify the information in this application.

[________________________________] Date: [__/__/____]
[APPLICANT SIGNATURE]

[________________________________] Date: [__/__/____]
[AUTHORIZED REPRESENTATIVE SIGNATURE]

13. DC PRACTICE NOTES

• Two-agency processing. DHCF sets policy and adjudicates eligibility; DHS-ESA receives applications and gathers documentation. Long-term-care applications are routed to the LTC Eligibility Unit. Track the application by DHS case number and DHCF MEEU log.
• Retroactive coverage. Always request three months of retroactive coverage on the cover sheet; failure to request can foreclose retroactive eligibility for institutional bills already incurred.
• Pre-eligibility planning. Consider half-a-loaf, promissory-note, or annuity strategies only with DC-licensed elder-law counsel; DC accepts properly drafted DRA-compliant annuities but scrutinizes promissory notes carefully.
• EPD Waiver capacity. The EPD Waiver has a finite slot allocation. Confirm the current waiting-list status with DACL ADRC at (202) 724-5626 before relying on home-and-community placement.
• Fair hearing. A denial, reduction, or termination notice triggers a 90-day window to request a fair hearing under D.C. Code § 4-210.01 and 29 DCMR Chapter 13. Aid pending may be available if requested within 15 days.
• Estate recovery. DHCF asserts estate-recovery claims under D.C. Code § 4-205.79. Hardship waivers exist; preserve evidence of caregiver-child residency and other equitable defenses.

14. SOURCES AND REFERENCES

• DC Department of Health Care Finance (DHCF) — https://dhcf.dc.gov/
• DHCF Medicaid Director Letter MDL 25-02 (2026 eligibility changes) — https://dhcf.dc.gov/publication/medicaid-director-letter-mdl-25-02-dc-medicaid-income-eligibility-changes-effective
• DHCF Medicaid Income Limits — https://dhcf.dc.gov/page/medicaid-income-limits
• DHCF "How to Apply for DC Medicaid" — https://dhcf.dc.gov/service/how-apply-dc-medicaid
• DHCF EPD Waiver Services — https://dhcf.dc.gov/page/epd-waiver-services
• DC Department of Aging and Community Living (DACL) — EPD Waiver — https://dacl.dc.gov/service/epd-waiver
• DACL Aging and Disability Resource Center: (202) 724-5626
• DHCF Long-Term Care Eligibility Office: (202) 442-5988
• 42 U.S.C. § 1396a; § 1396p (transfers, recovery, trusts) — https://www.law.cornell.edu/uscode/text/42/1396p
• Section 1915(c) DC EPD Waiver (Control No. 0334) — https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81286
• D.C. Law Library, Title 4 Chapter 2 (Medical Assistance) — https://code.dccouncil.gov/us/dc/council/code/titles/4/chapters/2
• 29 DCMR (DC Municipal Regulations) — Medicaid eligibility chapters
• Medicaid Planning Assistance — Washington DC profile — https://www.medicaidplanningassistance.org/medicaid-eligibility-washington-dc/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid eligibility figures and policies change frequently; verify all dollar limits, divisor amounts, and statutory citations with DHCF before filing. An attorney licensed in the District of Columbia must review and customize this packet before submission.